In Bulgaria, prostate cancer ranks second in frequency and represents 17% of all malignancies. It is mainly found in men over 50 years of age. 6 from everyone 10 cases of prostate cancer are diagnosed in men over the age of 65 years. The disease rarely develops before the age of 40. Prostate cancer is a malignant tumor, which affects the prostate gland of the male reproductive system. In most men, cancer develops at a very slow rate. In reality, many men with this disease never find out, that they have this disease. Early prostate cancer is confined to the prostate gland and the majority of patients can live for years without any indication of the problem.
The prostate gland is made up of several types of cells, but it is almost always carcinoma, derived from the glandular cells of the prostate. These cells produce fluid, which is a major part of sperm. The medical term for this most common type of prostate malignancy is adenocarcinoma.
Prostate cancer is characterized by grades and stages. The size and extent of the tumor's spread determine its stage. Early stage T1 and T2 prostate cancer is confined to the prostate gland. Stage T3 prostate cancer has progressed to tissues immediately outside the gland. Stage T4 prostate cancer means, that the disease may have affected adjacent structures such as the rectum, bladder and/or pelvic wall.
Symptoms
Prostate carcinoma (PC) detected by PSA tests or digital rectal examination (rectal douche) in men. If these two tests show deviations, it is necessary to appoint additional diagnostic tests. Prostate cancer often has no symptoms in the early stages of the disease, and some symptoms of advanced prostate cancer are:
- Frequent urination
- Weak or interrupted stream of urine or need to strain, to empty the bladder
- Blood in the urine
- Urgent need to urinate frequently at night
- Blood in the semen
- Onset of erectile dysfunction
- Pain or burning during urination, which is less common;
- Discomfort when sitting, caused by an enlarged prostate.
Sometimes other diseases, such as benign prostatic hyperplasia or an enlarged prostate, may have similar symptoms. Therefore, it is important to visit a specialist doctor in case of complaints.
Diagnostics and screening
Prostate cancer screening is recommended once a year for men over age 50 or earlier if risk factors are present. Approved screening methods are: digital rectal examination, ultrasound diagnostics and prostate-specific antigen (PSA). Combining digital rectal examination with PSA gives a better chance of early cancer diagnosis.
The diagnosis of prostate cancer is confirmed by:
- Consultation with a urologist
- Transrectal ultrasound
- Prostate biopsy with cytological examination
- Blood test
- Urine examination
- Prostate-specific antigen test
- Uroflowmetry
- Bone scan
- CT
- Magnetic resonance
Risk factors
The two main risk factors for prostate cancer are age and heredity.
Age
Prostate cancer is very rare in men younger than 40 years. As you age, the risk of prostate cancer increases significantly, as approx 60 % of the cases are diagnosed at the age of approx 65 years. This is the reason for its active demand among men over 50 years, through annual examinations at a urologist and PSA testing.
Heredity
It has been proven, that prostate cancer is more common in some families and heredity is also a risk factor. Having a close relative with prostate cancer (father, grandfather, uncle etc.) increases the risk of disease 2-3 times. In such cases, annual examinations should begin after age 45.
In recent years, the influence of certain cancer genes has been studied, BRCA1 and BRCA2, like breast cancer, which may affect the incidence of cancer, but there is still no firm evidence that this is the case.
Race
Cancer rates are higher among blacks and lower among Asians. It's curious, that the incidence among Asian immigrants to the United States is the same as that of the rest of the population there, which speaks, that harmful environmental factors also influence disease risk.
Overweight and diet
Current studies show, that perhaps obesity and being overweight could also increase the risk of disease.
Types of prostate cancer
The prostate gland is made up of several types of cells, but it is almost always carcinoma, derived from the glandular cells of the prostate. These cells produce fluid, which is a major part of sperm. The medical term for this most common type of prostate malignancy is adenocarcinoma. There are other types of prostate cancer such as sarcomas and transitional cell carcinomas, but they are very rare. The more cancer cells resemble normal ones, the more highly differentiated the cancer and the better the prognosis. Unfortunately, there are also forms, in which the cancer cells are so altered, that they don't look like normal at all, and then it is said, that the cancer is poorly differentiated.
stages
Prostate cancer is characterized by grades and stages. The size and extent of the tumor's spread determine its stage. Early stage T1 and T2 prostate cancer is confined to the prostate gland. Stage T3 prostate cancer has progressed to tissues immediately outside the gland. Stage T4 prostate cancer means, that the disease may have affected adjacent structures such as the rectum, bladder and/or pelvic wall.
Treatment
What are the treatment options for prostate cancer??
The most appropriate treatment depends on the size and location of the tumor, the results of laboratory tests of cancer cells, as well as the stage or extent of the disease.
Prostate cancer treatment can be local or systemic
Local procedures are used to remove or control cancer cells in a specific area. The possibilities, related to surgery and radiation therapy, are local. In the initial stages of breast cancer, surgery is the first step, with subsequent treatment based on surgical findings, the extent of disease and pathology.
Systemic treatments such as chemotherapy are used to kill or control cancer cells throughout the body. A patient may receive only one or a combination of several different forms of treatment.
Careful waiting (active monitoring)
The watchful waiting, more commonly referred to as active surveillance with options for later treatment, does not suggest prostate cancer treatment to date, in which your follow-up doctor finds no signs, that the cancer is growing more aggressively. This option is applicable to patients, in which the cancer is confined to the prostate gland and is low-aggressive.
Dynamic dispensary monitoring
There is a risk that a slow-growing cancer will suddenly accelerate its growth rate and spread beyond the original area of origin. Treatment may be risky in older patients, because with age increases the risk of complications and prolongs the recovery period. Also, patients should be prepared for more frequent blood and rectal examinations, as well as biopsies, which monitor the progression of the disease.
Radiation therapy
Radiation therapy is a combination of treatment methods, using ionizing radiation - high-energy X-ray radiation, which kill tumor cells. Ionizing radiation can be applied externally through the skin (percutaneously) – or by implanting radioactive materials in the area, where cancer cells are found (internal radiation or brachytherapy).
Radiation therapy, similar to other treatment methods in oncology (such as surgery or chemotherapy), has an effect on both tumor cells, as well as on the normal structures of the body. However, the body is able to regenerate healthy cells, which were damaged, and they to restore their proper functioning. Successful radiation therapy is the result of applying ionizing radiation through a personalized treatment plan to the tumor cells in the best and most efficient way so, that they be destroyed, and healthy tissues are minimally affected.
Brachytherapy
In this form of radiation therapy, a radioactive isotope is introduced into the prostate through a temporary implant, which allows the application of a large dose of ionizing radiation to the tumor. With this method, the surrounding tissues are less affected compared to the outside (percutaneously) irradiation. The introduction procedure takes about an hour and is performed on an outpatient basis. The method allows the entire prostate to be irradiated and reaches every cancer cell in it. The treatment course consists of a small number of procedures.
For which patients brachytherapy is suitable
This therapy may have a positive impact in the complex treatment of prostate cancer in patients with low, medium risk and in some cases selected groups of high risk patients.
Is there a risk with brachytherapy?
Although the irradiation is carried out in a small volume, due to the proximity of the prostate to the urethra, brachytherapy may cause more severe irritation during urination than external beam radiation therapy. Some patients require temporary catheterization. Patients, undergoing brachytherapy, they don't have to drive.
Externally (percutaneously) radiotherapy
External beam radiation is the most common form of radiation therapy. Detailed planning is done before treatment begins. During planning, specialists use CT images, held in the irradiation position, to determine the exact location for radiation treatment. During the radiation, the patient is placed on a special table, the beam is directed precisely to the prostate. The radiation lasts a few minutes and is usually administered five times a week for several weeks.
There are various technical variations of the exterior (percutaneously) irradiation. Some of them include:
High dose, three-dimensional radiation therapy (3DCRT)
Intensity modulated radiation therapy (IMRT); its dynamic rotational form called VMAT with or without image guidance of radiation therapy (IGRT)
Organ movement during radiation therapy
Internal organs are not immobile during radiation treatment and the prostate sometimes moves outside the intended radiation area due to differential filling of the bladder and rectum during radiation.
Specialized innovative system (CBCT) for precise patient positioning
A specialized innovative CBCT system is applied daily for each patient exposure, allowing precise positioning of the patient. This technology makes it possible to determine the position of the prostate during irradiation and allows the necessary corrections to be made in order to achieve maximum accuracy.
What are the advantages of Volume Modulated Rotational Radiation Therapy?
Radiation therapy is an alternative to surgery in many cases of early prostate cancer. In more advanced forms of the disease, when the pelvic lymph nodes are involved, surgery is not usually indicated and radiation therapy is the only treatment, giving a chance for healing. In high-risk cases, radiation therapy is combined with hormonal treatment.
Compared to older equipment, MR imaging allows for a higher dose to be delivered to the target tumor volume, while achieving maximum protection of healthy tissues and organs.
What are the side effects of external beam radiation therapy?
General reactions
In the beginning, some general reactions of the body such as fatigue are possible, Lack of appetite, nausea. They usually pass in the first days without radiation. Therefore, increase the hours of daily rest. If the reactions intensify, contact your doctor for help.
The following local reactions are observed when the prostate is irradiated, which usually begin in the middle of the treatment course and can last until 1 month after its completion.
- Nausea and less often vomiting – in some more sensitive patients it may last longer. The doctor is this one, who will prescribe medicines and a diet for you to complete the treatment without any problems.
- Bowel rumbling, how big, diarrhea - appear after 10 – 15 session. You may have several bowel movements a day. Your doctor will prescribe special medicines to relieve your symptoms. Diet is essential.
- Irritation of the anus, exacerbation of hemorrhoids - if you have hemorrhoids, they can become inflamed. More frequent bowel movements lead to irritation of the anus area. The doctor will prescribe suppositories or other medicines
- Frequent urination, at the end of which there may be a burning sensation – This is due to a small part of the bladder, which is irradiated, because the prostate is located between the bladder and the rectum. No matter how precise the radiation is even with the most advanced modern equipment available, a small part of the bladder receives some dose. Share with your doctor and you will get advice and medication to overcome this temporary effect.
- Loss of appetite, slight weight loss. These side effects pass ten days after the end of the treatment.
- The hair at the radiation site will thin or fall out at the end of the treatment, but they can recover after a few months.
A dietary regimen is essential for undergoing radiation therapy in this area. Categorically and necessarily stop smoking and drinking alcohol.
- Drink more fluids, but not too hot. Limit foods, rich in animal fats - fat, oil, bacon, pork and mutton. Consume mostly chicken and fish meat. Avoid the foods, which have a laxative effect and lead to gas formation: foods rich in cellulose - salads, fresh cabbage, peppers, rap, consume tomatoes peeled. From fruits, avoid pears, grapes, plums, as well as dry fruits.
- Consume cooked vegetables and soups. Sauces are allowed. Avoid beans and lentils.
- Do not consume spicy, hot and sour foods. Avoid nuts, as they irritate the intestines. Don't trust advice, who recommend nuts to increase the number of leukocytes.
- Do not use laxatives, without consulting your doctor.
Hygiene and rest regime
With your illness, your body needs more rest, than usual. Maintain your usual daily hygiene. Wash your genitals with lukewarm water and a gentle cleanser. Blot dry, without rubbing the skin. Use a moisturizing baby milk after bathing. During the treatment do not wear tight underwear, preferably it is cotton. The skin in the radiation field becomes more sensitive, it may become red and pigmented or itchy as with sun exposure. Your doctor may prescribe special skin treatment creams, which alleviate these reactions, while the treatment lasts.
After completing the last session, you should see your radiation therapist, to receive an epicrisis of the treatment carried out with advice on further conduct.
It contains answers to the questions:
- Will you continue with another treatment?
- Who and when will monitor your condition
- When will the radiation reactions die down
Behavior and life after radiation therapy
- 5 – 10 days after the end of the treatment, the appetite is gradually restored, the weight, your self-esteem. The stools and urination are normalized. The special diet should continue 2-3 weeks after the last radiation. Mistakes in diet can temporarily rekindle complaints.
- Wash with lukewarm water and skin-friendly detergents. Normal skin color will recover from pigmentation after a few baths.
- Manipulations in the area of the bladder and rectum are not recommended until one month after the treatment, except in an emergency.
- Do not expose the irradiated areas to the sun, they remain sensitive for up to a year. You can visit mountain and sea resorts, as guilt, you cover the places of irradiation. Bathing and swimming are not prohibited.
- Normal sexual contacts are completely possible 20 – 30 days after treatment. If desired, they should not be limited. A careful return to family and social life is important to your recovery. Your treating radiation therapist will give you the best advice on these delicate issues.
- For a certain period of time 1-2 month limit active movements and sports, associated with the lower half of the body, as well as weight lifting.
- Do not do physical therapy in the irradiated area or take hot baths.
What are the treatment options for metastatic disease?
When the disease spreads or metastasizes outside the prostate area, another type of treatment is usually used:
Hormonal therapy
Hormone therapy for prostate cancer is a treatment, which reduces the level of the male hormone testosterone, slowing tumor growth. This is done with medication, which stop the production of testosterone in the cells, or with surgery, in which the testicles are removed, which produce testosterone. Hormone therapy cannot cure advanced prostate cancer, but it can be used alone or in combination with other forms of treatment to improve quality of life and prolong survival.
Currently, clinical trials are being conducted around the world on the role and effect of types of hormone therapy. The most common form of hormone therapy uses drugs such as luteinizing hormone-releasing factor agonists (LHRH agonists). Blocking testosterone slows the rate of cancer growth. Other classes of drugs work, by preventing cancer cells from using testosterone.
A new class of drugs, called androgen biosynthesis inhibitors, are oral medications, which selectively block the production of hormones by the adrenal gland, which are also responsible for the growth of prostate cancer. The timing of their application varies and is often customized according to the patient's needs. These agents are prescribed for men with advanced disease, which no longer respond to hormone therapy, or such, who have been treated with chemotherapy and need additional treatment.
What are the benefits of hormone therapy??
Before radiation treatment, it can shrink the prostate, to lower the PSA level and improve the outcome of radiotherapy.
Which patients are suitable for hormonal treatment?
Hormone therapy is often used in men, undergoing radiation therapy. The men, whose disease has spread to the bones or lymph nodes, usually undergo hormone therapy. In treatment, patients and their doctors consider the effect on quality of life, the cost of the treatment and the potential effectiveness and safety for the patient concerned.
Is there a risk?, related to hormone therapy?
Hormonal drugs, which reduce testosterone production, are associated with many adverse reactions, including decreased libido, impotence, warm waves, weight gain, breast tenderness and enlargement, loss of muscle and bone mass, fatigue. Hormone therapy is associated with an increased risk of metabolic syndrome, diabetes, decreases-not of HDL (good cholesterol) and cardiovascular disease. Advanced prostate cancer can develop resistance to hormone therapy and it no longer works. When this happened, patients may undergo another type of treatment with proven survival prolongation.
Medical Oncology
Modern drug treatment of malignant tumors includes both classical cytotoxic and cytostatic drugs (chemotherapy with antitumor drugs), if there is any targeted therapy at all, it remains experimental.
Sometimes targeted therapy is administered alone, and in other cases together with classical chemotherapy. Modern hormonal treatment is an integral part of medical treatment (endocrine) therapy, which is extremely important in prostate cancer. With them, in certain cases, endocrine therapy can also be preceded by classical chemotherapy.
How long does chemotherapy last??
The treatment scheme, the number of courses and their method of administration are individual for each patient and are determined by an oncology committee. There are several different types of chemotherapy drugs, which are used nowadays. Some of them function better on their own, others work in combination. The doctor may prescribe a combination of chemotherapy drugs - the so-called. chemotherapy regimen. A small number of chemotherapeutic agents exist, which can be taken as tablets by mouth or injected intramuscularly or subcutaneously into fatty tissue, but the majority of them are administered intravenously through a system.
According to national standards, based on the golden rules of the European (ESMO) and the American one (DISGUST) oncology associations (including NCCN).
Immunotherapy
Boosting the patient's immune system to increase its effectiveness in destroying cancer cells has been recognized as a potential therapeutic strategy in prostate cancer. Cipu-levcel -T (Provenge®) is a new immunotherapies (created with the patient's own cells), designed to stimulate the natural ability of immune cells in the blood to attack prostate cancer cells more effectively and prolong survival.
